Nursing Elites

1. A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent?

• A. Relex incontinence
• B. Urge incontinence
• C. Total incontinence
• D. Functional incontinence

Correct answer: D

Rationale: Functional incontinence occurs when a client develops an urge to void but may not be able to reach the toilet in time. In this scenario, the client had the urge to use the restroom but was unable to make it in time, leading to incontinence. Functional incontinence may be related to conditions that cause the client to forget bladder sensation until the last minute, such as cognitive changes, or the client may have mobility problems that prevent her from reaching the bathroom in time. Choice A, Reflex incontinence, is incorrect as reflex incontinence is characterized by the involuntary loss of urine due to hyperreflexia of the detrusor muscle. Choice B, Urge incontinence, is not the correct answer as urge incontinence is the involuntary loss of urine associated with a strong desire to void. Choice C, Total incontinence, is also incorrect as it refers to the continuous and unpredictable loss of urine, not specifically related to the inability to reach the toilet in time.

2. Which of the following vital signs can be expected in a child that is afebrile?

• A. Rectal Temp of 100.9 degrees F.
• B. Oral Temp of 38 degrees C.
• C. Axillary Temp of 98.6 degrees F.
• D. All of the above are incorrect.

Correct answer: C

Rationale: The correct answer is the axillary temperature of 98.6 degrees F. Afebrile means without a fever, and an axillary temperature, which is taken in the armpit, is considered normal at 98.6 degrees F. Choice A is incorrect as a rectal temperature of 100.9 degrees F indicates a fever. Choice B is incorrect as an oral temperature of 38 degrees C is also indicative of a fever. Choice D is incorrect as not all options are wrong; only choices A and B are incorrect for an afebrile child.

3. Which of these guidelines would a healthcare professional follow when measuring a patient's weight?

• A. The patient is always weighed wearing only undergarments.
• B. The type of scale matters and should be consistent day to day.
• C. The patient should remove heavy outer clothing, shoes, and jackets before weighing.
• D. Attempts should be made to weigh the patient at approximately the same time of day if a sequence of weights is necessary.

Correct answer: D

Rationale: When measuring a patient's weight, it is important to ensure accuracy and consistency. If a sequence of repeated weights is necessary, the healthcare professional should attempt to weigh the patient at the same time of day and with the same types of clothing worn each time. It is crucial to use a standardized balance or electronic standing scale for accurate weight measurement. Choice A is incorrect as patients should remove heavy outer clothing, shoes, and jackets before being weighed for accurate results. Choice B is incorrect because the type of scale used does matter and should be consistent for reliable weight tracking. Choice C is incorrect as patients should not leave on heavy outer clothing, shoes, or jackets as these items can add to the weight recorded inaccurately.

4. A nurse caring for a client diagnosed with pertussis is ordered to maintain droplet precautions. Which of the following actions of the nurse upholds droplet precautions?

• A. Assign the client to stay in a negative-pressure room
• B. Use sterilized equipment when sharing between this client and another person with pertussis
• C. Wear a mask if coming within 3 feet of the client
• D. Both A and C

Correct answer: C

Rationale: When caring for a client requiring droplet precautions, it is essential for the nurse to wear a mask when within 3 feet of the client. This practice helps prevent the transmission of droplet particles that may be produced when the client coughs or sneezes. Assigning the client to a negative-pressure room is not typically necessary for droplet precautions unless specifically indicated for airborne precautions. Using sterilized equipment when sharing between clients with pertussis is important for infection control but does not directly relate to droplet precautions. Therefore, the correct action to uphold droplet precautions in this scenario is to wear a mask when coming within close proximity to the client.

5. When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?

• A. After menopause, blood pressure readings in women are usually higher than those taken in men.
• B. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
• C. Blood pressure measurements in people who are overweight are usually higher than those of people who are at a normal weight.
• D. A teenager's blood pressure reading may be lower than that of an adult.

Correct answer: B

Rationale: When assessing blood pressures, it is important to consider that the blood pressure of African-American adults is typically higher than that of non-Hispanic White adults of the same age. This is significant as Black individuals in the United States have a higher prevalence of hypertension compared to other groups. Blood pressure readings in women are generally higher than in men after menopause. Additionally, blood pressure measurements in overweight individuals are typically higher than those in individuals of normal weight. While teenagers may have lower blood pressure readings than adults, it is crucial to recognize the trend of a gradual rise in blood pressure throughout childhood and into adulthood. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they do not reflect the typical blood pressure differences observed in various populations.

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